Faculty Bibliography

The incidence and importance of bone marrow involvement and/or early bone lesions in multiple myeloma (MM) precursor diseases is largely unknown. This study prospectively compared the sensitivity of several imaging modalities in monoclonal gammopathy of undetermined significance (MGUS), smoldering multiple myeloma (SMM) and MM. Thirty patients (10 each with MGUS, SMM and MM) were evaluated with skeletal survey, [(18)F]FDG-PET/CT, [(18)F]NaF-PET/CT and morphologic dynamic contrast enhanced (DCE)-MRI. An additional 16 SMM patients had skeletal surveys and FDG-PET/CT. Among MGUS patients, DCE-MRI found only one focal marrow abnormality; other evaluations were negative. Among 26 SMM patients, five (19%) were re-classified as MM based on lytic bone lesions on CT and six had unifocal or diffuse marrow abnormality. Among MM, marrow abnormalities were observed on FDG-PET/CT in 8/10 patients and on DCE-MRI in nine evaluable patients. Abnormal NaF uptake was observed only in MM patients with lytic lesions on CT, providing no additional clinical information.

BACKGROUND: This study aims to quantify changes in fibroblast growth factor 19 (FGF19) and bile acids (BAs) in patients with uncontrolled type 2 diabetes randomized to Roux-en-Y gastric bypass (RYGB) vs intensive medical management (IMM) and matched for similar reduction in HbA1c after 1 year of treatment. METHODS: Blood samples were drawn from patients who underwent a test meal challenge before and 1 year after IMM (n = 15) or RYGB (n = 15). RESULTS: Mean HbA1c decreased from 9.7 to 6.4 % after RYGB and from 9.1 to 6.1 % in the IMM group. At 12 months, the number of diabetes medications used per subject in the RYGB group (2.5 +/- 0.5) was less than in the IMM group (4.6 +/- 0.3). After RYGB, FGF19 increased in the fasted (93 +/- 15 to 152 +/- 19 pg/ml; P = 0.008) and postprandial states (area under the curve (AUC), 10.8 +/- 1.9 to 23.4 +/- 4.1 pg x h/ml x 10(3); P = 0.006) but remained unchanged following IMM. BAs increased after RYGB (AUC x10(3), 6.63 +/- 1.3 to 15.16 +/- 2.56 muM x h; P = 0.003) and decreased after IMM (AUC x10(3), 8.22 +/- 1.24 to 5.70 +/- 0.70; P = 0.01). No changes were observed in the ratio of 12alpha-hydroxylated/non-12alpha-hyroxylated BAs. Following RYGB, FGF19 AUC correlated with BAs (r = 0.54, P = 0.04) and trended negatively with HbA1c (r = -0.44; P = 0.09); these associations were not observed after IMM. CONCLUSIONS: BA and FGF19 levels increased after RYGB but not after IMM in subjects who achieved similar improvement in glycemic control. Further studies are necessary to determine whether these hormonal changes facilitate improved glucose homeostasis.

Acquired QT prolongation can be caused by cardiac and noncardiac medications. Macrolides are known to prolong QT interval. Rarely, it can be fatal. We report a case of torsades de pointes in a patient taking clarithromycin as a part of Helicobacter pylori eradication regimen.

Many primary care physicians are not properly educated to recognize substance use disease as a separate disease entity that requires legitimate medical care and consideration. Additionally, many physicians do not perceive substance use conditions as being part of their responsibility and that they should remain as case managers throughout the patient's treatment. This primary care Physician Alcoholism/Addiction Training Program (PAAT) serves to train first-year medical residents to properly diagnose, treat, and refer chemical dependent patients. The target physician population is first-year primary care medical residents. The content includes volunteer AA members who serve as teaching buddies, overview of the medical and psychiatric complications, motivational interviewing techniques, and practice sessions. The success of this program was assessed by utilizing the Wilcoxon Matched-Pairs Signed Ranks Pre-/Post-Test. Most primary care physicians fail to perceive drug addiction as a separate disease entity that deserves to be a part of their responsibility to diagnose, treat, and properly refer, while remaining as ongoing case managers. The Physician Alcoholism/Addiction Training Program (PAAT) encourages the outlook for successful long term recovery from addictions by providing information, resources and beginning skills practice for effective screening, intervention, proper referral, counseling and medical treatment of substance use disorders. The curriculum is presented each month for 3 hours over four consecutive sessions, and is anchored by a primary care physician with addiction credentials. The course incorporates AA members into its program where the physician students are individually paired up to an AA Buddy in order to help them understand the complexity of the human component of the disease and the possibility for successful recovery. The physician students are also given the opportunity to utilize the motivational techniques that they learn with the use of professional actors who take on the persona of addicted patients. By doing so, they learn how to develop a rapport with the patient leading to a successful medical screening/diagnosis, helping the patient understand and acceptance the disease model, proper intervention, and treatment. This course also includes a Q&A with a physician in recovery, a group discussion with the AA Buddies panel, information on addiction neurophysiology, medical complications, and psychiatric comorbidity. The centerpiece of the curriculum is having the physician students present their Buddies' histories into recovery. Pre-/post-test mean value analysis using Wilcoxon Matched-Pairs Signed Ranks Test findings show that the PAAT changed the students' perception that rather than a deficiency in moral character, substance use is a chronic relapsing medical disease. Students reported an increase in their ability to recognize common physical signs and symptoms of addiction, more confidence in assessing and accurately diagnosing chemical dependency, increased ability to make an accurate referral, and overall more willing to treat chemically dependent patients. The PAAT is a method to improve physicians' skill sets and clinical abilities to better treat chemically dependent patients by altering negative perceptions. Acceptance of chemical dependency as a medical disease widens the physician students' responsibilities to provide proper case management and overall medical treatment

BACKGROUND: In the patient-centered medical home model of health care, both health care providers (HCPs) and patients must understand their respective roles and responsibilities, view the other as a partner, and use communication skills that promote shared decision making. This is particularly necessary in chronic conditions where outcomes depend on behavior change and in underserved populations where the burden of chronic disease is high. OBJECTIVE: The objectives of this study are to determine if a Patient Empowerment Program (PEP) (1) is acceptable to patients and feasible across multiple clinical sites; (2) will increase patient preference for control in medical decision making, improve patient perceptions of patient-HCP communication, and increase patient activation; (3) is associated with an increase in diabetes self-management behaviors; and (4) has an effect on hemoglobin A1c (HbA1c) level. METHODS: This study recruited English-speaking adult patients with type 2 diabetes mellitus from three urban clinical sites in New York City and randomized them to an immediate intervention group that completed the PEP intervention or a deferred intervention group that served as a wait-list control and completed the PEP intervention after 3-4 months. The PEP intervention consists of two facilitated small group sessions. Session 1 focuses on defining HCP and patient roles in the medical encounter by introducing ideal communication behaviors in each role and by providing both positive and negative examples of patient-HCP encounters. Session 2 focuses on practicing communication skills by role-playing with actors who serve as standardized health care providers. After the role play, participants set goals for their own health care and for future interactions with their HCPs. Outcome measures include the Patient Activation Measure; Ask, Understand, Remember Assessment; Krantz Health Opinion Survey; SF-12v2 Health Survey; Diabetes Self-Management Questionnaire; and HbA1c. These measures will be assessed at the time of enrollment, after the waiting period (deferred intervention only), and then postintervention at 1 week, 3 months, and 6 months. RESULTS: Study recruitment occurred from November 2014 to June 2015, with a total of 80 patients enrolled. To date, 45 participants have attended at least one session of the PEP intervention. Further intervention sessions and post-intervention follow-up are ongoing, with data collection set to be completed in April 2016 and results of data analysis available by June 2016. CONCLUSIONS: From preliminary participant self-report data, our PEP intervention is acceptable to low-income, low-health literate patients and feasible to hold across multiple clinical sites. Participants have reported learning specific ways to change their behaviors at their next HCP visit (eg, stating their opinions, asking more questions). With the forthcoming quantitative data on participant attitudinal and behavior change, the PEP intervention may ultimately empower participants within the medical encounter and improve health outcomes.

Bioethics has become a common course of study in medical schools, other health professional schools, and graduate and undergraduate programs. An analysis of past ethical scandals, as well as the bioethics apparatus that emerged in response to them, is often central to the discussion of bioethical questions. This historical perspective on bioethics is invaluable and demonstrates how, for example, the infamous Tuskegee syphilis study was inherently racist and how other experiments exploited mentally disabled and other disadvantaged persons. However, such instruction can resemble so-called Whig history, in which a supposedly more enlightened mindset is seen as having replaced the "bad old days" of physicians behaving immorally. Bioethical discourse-both in the classroom and in practice-should be accompanied by efforts to historicize but not minimize past ethical transgressions. That is, bioethics needs to emphasize why and how such events occurred rather than merely condemning them with an air of moral superiority. Such instruction can reveal the complicated historical circumstances that led physician-researchers (some of whom were actually quite progressive in their thinking) to embark on projects that seem so unethical in hindsight. Such an approach is not meant to exonerate past transgressions but rather to explain them. In this manner, students and practitioners of bioethics can better appreciate how modern health professionals may be susceptible to the same types of pressures, misguided thinking, and conflicts of interest that sometimes led their predecessors astray.